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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOG[KHANNA AD.,,4i.P.H. <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . SE04EUn,California 95201 <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468--W27 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> ' GEOTECHNICAL DATA <br /> ENVIRONMENTALISITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY ANDiOR FACILITY <br /> LOCATED AT 2-C1 L l _ �i s i `��C <br /> (Street Addr (City) <br /> EiL:ItEtiY AUTHORIZE <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (!f Applicable) ` <br /> OWNERIOPERATOR: �..�— <br /> (Pl a (Title) <br /> (S,&-=ture) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) {zip curie) <br /> PHONE: ( 7 n <br /> DATE: <br /> Lit 23 Oil (REV 2/8/931 wp ' Page: 9 <br /> A D,viiton ut San juaqu:n Gutty Health C.,cc Scrvicc8 <br />